The Issue The issue in this case is whether the Agency for Health Care Administration (AHCA) should enroll the Petitioner, Oscar Sansoni, as a Medicaid provider of support coordination services.
Findings Of Fact In 1990, the former Department of Health and Rehabilitative Services (HRS) preliminarily confirmed a report of abuse or neglect against the Petitioner, Oscar Sansoni (report No. 90-045389). The Petitioner asked that the report be expunged and asked for formal administrative proceedings when HRS denied his request (DOAH Case 90-4332C). Upon commencement of the hearing in DOAH Case 90-4332C, the Petitioner withdrew his request for expunction "upon condition that such withdrawal would not prejudice his right to request, at a later date, further proceeding on the issue of an exemption from disqualification for employment." A Recommended Order of Dismissal was entered in the case on October 26, 1990, on the basis of the Petitioner's withdrawal of his expunction request. On August 6, 1991, a Final Order was entered on the basis of the Recommended Order of Dismissal; it denied the expunction request and confirmed the report. The Petitioner was initially certified by HRS to provide support coordination services under Florida's Medicaid waiver program in November 1993. He provided those services in District 6 and in District 14, but not without some problems in both districts. The first survey of the Petitioner conducted in District 14 on September 21, 1994, revealed five major areas of concern: support plans did not authorize services; (2) cost plans (plans of care) did not authorize purchase of services; (3) case notes did not substantiate billing; (4) case notes were not in sufficient detail; and (5) planning prior to changing client support was inadequate. As a result, District 14 withdrew the Petitioner's ability to process billings for 90 days. The first survey of the Petitioner conducted in District 6 on October 21, 1994, revealed most of the same concerns as in District 14. (The exception was that the Petitioner was not criticized for inadequate planning.) To the Petitioner's credit, he improved following the initial surveys. A follow-up survey conducted in District 14 on January 24, 1995, revealed that the Petitioner was in full compliance. A follow-up survey in District 6 also revealed progress, but the Petitioner was not considered to be providing better than adequate services there. On December 29, 1994, the Petitioner signed a verification that he had obtained or would soon be obtaining a background screening, as required of all HRS Developmental Services Medicaid waiver support coordinators. During a routine review on or about May 24, 1995, HRS discovered that the Petitioner had not yet obtained or even applied for a background screening. HRS conducted a background screening of the Petitioner which revealed the confirmed report of abuse or neglect, report No. 90-045389. As a result, HRS took action to revoke the Petitioner's Medicaid waiver certification. The outcome of the revocation proceeding is not clear from the record, but it appears from the evidence that the Petitioner was required to relinquish 34 District 6 case files for handling by other support coordinators. Review of those files revealed that 15 of the 34 had no support plans or overdue support plans. Most of the case files had no case notes. The Petitioner asked for an extension of time until June 5, 1995, to submit missing case notes and support plans. On June 9, 1995, he submitted some but not all of the missing case notes and support plans. More missing case notes and support plans were submitted on July 27, 1995, along with billings for support services. Still more missing case notes and support plans with additional billings for support services were submitted on January 12, 1996. The Petitioner let it be known that he was spacing the submission of these documents to optimally serve his cash-flow needs. District 6 reviewed the Petitioner's case notes and support plans after January 12, 1996, and found them to be extremely unprofessional, contrary to state statute and rule relative to confidentiality, and lacking in substance relative to the implementation of goals on the support plan. Many support plans were late. The Petitioner failed to comply with many of the assurances required of Medicaid waiver support coordinators. At a later date, the Petitioner applied for Medicaid waiver certification on behalf of Dare to Dream, Inc. HRS denied the application, and the Petitioner requested formal administrative proceedings. The case was referred to DOAH, where it was given Case No. 96-3199. Case No. 96-3199 was set for final hearing on September 20, 1996, but HRS filed a Motion for Suggestion of Mootness on September 17, 1996. In the motion, HRS conceded that the Petitioner met all of the certification criteria set out in Florida Administrative Code Rule 59G-8.200(12)(b)20 and that there was no valid, legal ground for denying certification. It gave assurance that HRS would issue the Medicaid waiver certification letter "within the next week." The Petitioner initially opposed the motion "out of frustration" but withdrew his opposition at a telephone hearing held on the motion on September 18, 1996, and an Order Dismissing Proceeding, Relinquishing Jurisdiction, and Closing File was entered on September 19, 1996, returning jurisdiction to HRS for issuance of the Medicaid waiver certification. HRS issued a one- year Medicaid waiver certification to Dare to Dream, Inc., on September 18, 1996. The letter transmitting the one-year certification to Petitioner explained that, effective January 1, 1995, all providers of Developmental Services/Home and Community Based Services of Support Coordination were required to have a Medicaid provider number. HRS agreed to forward the Petitioner's completed application for a provider number to the Agency for Health Care Administration (AHCA). When HRS forwarded the Petitioner's application for enrollment as a Medicaid provider, HRS included its evaluation of the Petitioner's previous performance and a strong recommendation that the application be denied. AHCA received the Petitioner's application on October 31, 1996. On January 9, 1997, AHCA advised the Petitioner that it intended to deny the application: (1) because, contrary to representations in the application, the Petitioner's Medicaid waiver certification had been revoked, not suspended, by HRS in May 1995; (2) because the Medicaid waiver certification had not been restored; (3) because the Petitioner had on his record a confirmed report of abuse or neglect; and (4) because, for the foregoing reasons, as well as the Petitioner's performance history as a provider of support coordination services for HRS, AHCA concurred with HRS' recommendation that the application be denied. The Petitioner, in his rebuttal, explained: (1) that he understood his Medicaid waiver certification to have been suspended, not revoked; and (2) that, besides, it was restored by the time of his application. He also had admitted in evidence documentation relating to DOAH Case Nos. 90-4332C and 96-3199 (which provide some of the support for Findings 1 and 10-13, supra.) However, the Petitioner put on no evidence contrary to the other grounds for HRS' recommendation that the application be denied.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order denying the Petitioner's application for enrollment as a Medicaid provider. RECOMMENDED this 15th day of January, 1998, at Tallahassee, Leon County, Florida. J. LAWRENCE JOHNSTON Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 15th day of January, 1998. COPIES FURNISHED: Jack B. Pugh, Esquire Suite 1080 1645 Palm Beach Lakes Boulevard West Palm Beach, Florida 33401 Gordon Scott, Esquire Agency for Health Care Administration Building 3, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308 Sam Power, Agency Clerk Agency for Health Care Administration Fort Knox Building 3, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308 Jerome W. Hoffman, General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308
The Issue The issue for determination is whether Respondent committed the offense set forth in Petitioner's letter of agency action dated March 9, 2012, and, if so, what action should be taken.
Findings Of Fact At all times material hereto, New Life was issued individual Medicaid provider number 140680900. At all times material hereto, New Life was enrolled as an assisted living facility. At all times material hereto, New Life had a valid Medicaid Provider Agreement with AHCA (Agreement). Under the Agreement, New Life was authorized to provide assistive living services to Medicaid recipients. The Florida Medicaid Assistive Care Services Coverage and Limitations Handbook, effective July 2009, hereinafter Handbook, provides, among other things, requirements of Medicaid home health services providers and sets forth pertinent Medicaid policies and service requirements. The Handbook is provided to each Medicaid provider upon enrollment into the Medicaid program and is available online. Each provider is expected and presumed to be familiar with the Handbook. The Handbook was incorporated by reference into rule 59G-4.025, Assistive Care Services. No dispute exists that, at all times material hereto, New Life was an assistive care services provider as defined by the Handbook. The Handbook provides in pertinent part: Recipients receiving Assistive Care Services must have a complete assessment at least annually . . . or sooner if a significant change in the recipient's condition occurs . . . . An annual assessment must be completed no more than one year plus fifteen days after the last assessment. An assessment triggered by a significant change must be completed no more than fifteen days after the significant change. The assessment for a resident of a ALF . . . must be completed by a physician or other licensed practitioner of the healing arts (Physician Assistant, Advanced Registered Nurse Practitioner, Registered Nurse) acting within the scope of practice under state law, physician assistant or advanced registered practitioner. * * * The assessment for ALF [assisted living facility] residents must be recorded on the Resident Health Assessment for Assisted Living Facilities, AHCA Form 1823. * * * Along with the annual assessment requirement, all recipients receiving ACS [Assistive Care Services] must have an updated Certification of Medical Necessity for Medicaid Assistive Care Services, AHCA- Med Serv Form 035, July 2009, signed by a physician or other licensed practitioner of the healing arts (Physician Assistant, Advanced Registered Nurse Practitioner, Registered Nurse) and the Resident Service Plan for Assistive Care Services, AHCA-Med Serv Form 036, July 2009, completed and available in the recipient's case file at the facility. * * * Every ACS recipient must have a service plan completed by the ACS service provider. The Resident Service Plan for Assistive Care Services, AHCA-Med Serv Form 036, July 2009, shall be used for each recipient receiving ACS. The form must be included in the recipient's case file at the facility. The ALF, RTF [residential medical facility] and AFCH [adult family care home] are responsible for ensuring the service plan is developed and implemented. * * * The Resident Service Plan for Assistive Care Services (AHCA-Med Serv Form 036) must be completed within 15 days after the initial health assessment or annual assessment, be in writing and based on information contained in the health assessment. . . . * * * A new service plan is required on an annual basis or sooner if a significant change in the recipient's condition occurs. The new service plan must be completed no more than 15 days after the annual assessment or an assessment because of a significant change in the recipient's condition. * * * In addition to records required by the applicable licensure standards, ACS records that must be kept include: Copies of all eligibility documents; Health Assessment Forms, AHCA Form 1823 . . .; Certification of Medical Necessity for Medicaid Assistive Care Services, AHCA-Med Serv Form 035; The Resident Service Plan for Assistive Care Services, AHCA-Med Serv Form 036; and The Resident Service Log, AHCA-Med Serv Form 037. This documentation must be maintained at the facility, kept for at least five years, and be made available to the Agency for Health Care Administration monitoring or surveyor staff or its designated representative, upon request. . . . * * * ACS documentation may be in electronic format. The original, signed . . . documents must be kept in the recipient's case file in the facility . . . for audit, monitoring and quality assurance purposes. . . . Handbook at P 2-7 through 2-11. AHCA's investigator performed a site visit at New Life on December 8, 2011. The investigator reviewed case files of residents for the service-period covering January 1, 2011, through November 30, 2011 (service-period). AHCA's investigator found deficiencies in the case files of seven residents at New Life: M.B.; R.F.; E.H.; R.J.; I.M.; K.L.; and J.S. Additional documents, not contained in the case files during the site visit, were provided subsequent to the site visit. Regarding Resident M.B., the Health Assessment and the Resident Service Plan were dated August 17, 2010, which was after the service-period; and the Certification of Medical Necessity was dated March 28, 2012, which was not within the service-period and after the site visit. The evidence demonstrates that the case file of Resident M.B. lacked the Health Assessment, Resident Service Plan, and Certification of Medical Necessity for the service- period. As to Resident R.F., the Health Assessment was dated January 1, 2011, which was within the service-period but not up- to-date; the Resident Service Plan was up-to-date; and the Certification of Medical Necessity was dated March 1, 2012, which was not within the service-period and after the site visit. The evidence demonstrates that the case file of Resident R.F. lacked the Health Assessment and Certification of Medical Necessity for the service-period. Regarding Resident E.H., the Health Assessment was dated January 24, 2011, and was up-to-date; the Resident Service Plan was not provided; and the Certification of Medical Necessity was dated September 27, 2002, with no more recent Certification of Medical Necessity. The evidence demonstrates that the case file of Resident E.H. lacked the Resident Service Plan and Certification of Medical Necessity for the service-period. As to Resident R.J., the parties stipulated that the Health Assessment was up-to-date; the Resident Service Plan was not provided; and the Certification of Medical Necessity was dated February 29, 2012, which was not within the service-period and after the site visit. The evidence demonstrates that the case file of Resident R.J. lacked the Resident Service Plan and Certification of Medical Necessity for the service-period. Regarding Resident I.M., the Health Assessment and the Resident Service Plan were up-to-date; and the Certification of Medical Necessity was dated March 1, 2012, which was not within the service-plan and after the site visit. The evidence demonstrates that the case file of Resident I.M. lacked the Certification of Medical Necessity for the service-period. As to Resident K.L., the Health Assessment was dated March 1, 2012, which was not within the service-period and after the site visit; the Resident Service Plan was not provided; and the Certification of Medical Necessity was provided, but the date as to the year was unintelligible even though the month and day were intelligible, i.e., March 1. The evidence demonstrates that the case file of Resident K.L. lacked the Health Assessment, Resident Service Plan, and Certification of Medical Necessity for the service- period. Regarding Resident J.S., the Health Assessment was dated August 22, 2009, which was not within the service-period; the Resident Service Plan was not provided; and the Certification of Medical Necessity was dated February 29, 2012, which was not within the service-period and was after the site visit. The evidence demonstrates that the case file of Resident J.S. lacked the Health Assessment, Resident Service Plan, and Certification of Medical Necessity for the service period. The Director and owner of New Life is Ethel Newton. Ms. Newton has been the Director and owner for the past 13 years. She was not familiar with the Health Assessment form, the Resident Service Plan form, or the Certification of Medical Necessity form. Ms. Newton advised AHCA's investigator that she was not familiar with the forms and admitted same at the hearing. Ms. Newton historically depended upon the assistance of the Department of Children and Family Services (DCF) to complete any required forms. She depended upon DCF until 2005 when DCF closed its local office which had been assisting her. After DCF closed its local office, Ms. Newton depended upon the residents' case managers at New Horizons, an agency where the residents' physicians are located, to complete any required forms. Five of the seven residents had case managers at New Horizons; J.S. and E.H. did not have case managers at New Horizons. E.H. is no longer a resident at New Life. Ms. Newton is willing to cooperate with AHCA and do whatever it takes to have the required forms completed timely and correctly. The evidence does not demonstrate that Ms. Newton intentionally failed to complete the required forms. None of the seven residents were harmed as a result of the deficiencies in the documentation. No evidence was presented demonstrating that New Life has any prior administrative sanction or penalty. No evidence was presented demonstrating that New Life has any prior violations.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order: Finding that New Life Assisted Living, Inc., d/b/a New Life Assisted Living Facility, violated Florida Administrative Code Rule 59G-9.070(7)(e) by failing to have in the case files of Resident M.B., Resident K.L., and Resident J.S. a Health Assessment, Resident Service Plan, and Certification of Medical Necessity for the service-period covering January 1, 2011, through November 30, 2011; by failing to have in the case file of Resident R.F. a Health Assessment and Certification of Medical Necessity for the service-period covering January 1, 2011, through November 30, 2011; by failing to have in the case file of Resident E.H. and Resident R.J. a Resident Service Plan and Certification of Medical Necessity for the service-period covering January 1, 2011, through November 30, 2011; and by failing to have in Resident I.M.'s case file a Certification of Medical Necessity for the service-period covering January 1, 2011, through November 30, 2011; Requiring New Life Assisted Living, Inc., d/b/a New Life Assisted Living Facility to enter into a corrective action plan; and Imposing a fine against New Life Assisted Living, Inc., d/b/a New Life Assisted Living Facility in the amount of $1,750.00. S DONE AND ENTERED this 14th day of November, 2012, in Tallahassee, Leon County, Florida. ERROL H. POWELL Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 14th day of November, 2012.
Findings Of Fact Billings for home health care services once made CCI the recipient of substantial Medicaid moneys. By resort to, among other things, "a variety of different types of statistical investigations," (T.82) the Office of Program Integrity within HRS' Medicaid Office is "continuously asking the question, do we get what we pay for?" Id. A separate, legislative agency, a unit of the Office of the Auditor General, investigates allegations of Medicaid fraud. Investigation In February of 1990, Ellen Williams, a medical health care program analyst in HRS' Office of Program Integrity, noticed that CCI was "suddenly showing up as either number one or number two in the State, and . . . was intrigued why a home health agency in Palatka would be [b]illing to the extent it appeared that they were." T.36. She "requested a printout of their billings" (T.37) and opened a file. Not long afterwards, Ms. Williams learned that the Medicaid Fraud Control Unit (MFCU) in the Auditor General's Office "had basically a new review of the same agency." T.37. MFCU investigators copied "a number of boxes" (T.116) of CCI's records, including "pieces of files" for ten of the 49 patients whose files HRS subsequently attempted to obtain from CCI. T.53. As far as the evidence showed, MFCU did not obtain "the entire files on any of these people." Id. In early May of 1990, Ms. Williams received an unsigned investigative report the Medicaid Fraud Control Unit had prepared. On the strength of this report, at her supervisor's direction, she prepared a letter which was sent to CCI by certified mail on May 20, 1991. Petitioner's Exhibit No. 3. She did not attempt at that time to verify the allegations in the MFCU report. Prosecution The letter dated May 20, 1991, initiated a recoupment and termination proceeding, Conval-Care, Inc. v. Department of Health and Rehabilitative Services, No. 91-4020, intended to end CCI's "participation in the Florida Medicaid program for [alleged] violation of federal and state laws and regulations respecting the Medicaid program," stating: Information has been received from the Medicaid Fraud Control Unit of the Office of the Auditor General (MFCU) to the effect that you have billed and been paid $591,082.00 for services that are not covered by Medicaid. Petitioner's Exhibit No. 3. HRS also sought to recover the alleged overpayment, and impose an administrative fine. The letter did not allege times. (HRS later concluded that the overbillings alleged in the letter occurred between December of 1989 and November of 1990, but HRS never sought leave to amend to allege this, and took no other step to limit the allegations in the recoupment and termination proceeding.) In response to CCI's request for formal administrative proceedings, HRS referred Case No. 91-4020 to the Division of Administrative Hearings. Discovery and Further Investigation On September 23, 1991, while Case No. 91-4020 was pending at the Division of Administrative Hearings, HRS' Ellen D. Williams wrote CCI's Inez Browning, as follows: In order to complete the Medicaid review of services billed by Conval-Care, Inc. to the Department of Health and Rehabilitative Services, it will be necessary to obtain completed home health records on a selected statistical sample of recipients. I plan to arrive at your Palatka office on Tuesday, October 8, 1991, for the purpose of copying the records for the individuals on the attached list. Please have them available at that office. If you have any problems or questions, please call me at (904) 488-3588. Respondent's Exhibit No. 1. Although not identified as such, the list of names was purportedly a random sample of Medicaid beneficiaries to whom CCI had provided services between December of 1989 and May of 1991, a period during which CCI's alleged overbillings were even higher. In response to Ms. Williams' letter of September 23, 1991, counsel for CCI wrote Ms. Williams, on September 30, 1991, as follows: Please recall that your office, due in large part to your actions, is involved in litigation with Conval-Care, Inc. As a result, any request for documents must be pursued through appropriate discovery channels pursuant to the Florida Rules of Civil Procedure. No records will be provided as a result of your letter of September 23rd. If you appear at the door, you will be refused entry. You referred to a "statistical sample" of recipients, yet requested information concerning both recipients whose records have already been provided and the remaining recipients whose records were not provided during the initial investigation. This hardly reflects any statistical sampling. Further, your letter contradicts your sworn testimony in which you indicated there was no pending investigation of Conval-Care, Inc. by DHRS. In any event, Conval-Care, Inc. is a represented party in active litigation with your agency and neither you or any other representative from DHRS may contact Conval- Care, Inc. or any of its employees without my consent. You and others at the agency may have realized the weakness of your claims against Conval-Care, Inc., since the credibility of several of your key witnesses has been seriously undermined, but we will not permit you to go on a fishing expedition to try to develop new allegations against our client. You made your case Ms. Williams, now live with it. If DHRS must seek other documents related to the matters at issue, its attorneys should know how to do that. Respondent's Exhibit No. 2. HRS did not file any request for production in Case No. 91-4020 under Fla. R. Civ. P. 1.310(b), 1.350 or 1.351, which are applicable to administrative proceedings by virtue of Rule 60Q-2.019, Florida Administrative Code. Instead, attaching the same list of 49 names that Ms. Williams had attached to her letter of September 23, 1991, counsel for HRS wrote CCI's counsel, on October 17, 1991, as follows: Pursuant to Chapter 400.484 and 409.913 Florida Statutes, representatives of the Department of Health and Rehabilitative Services intend to copy certain records in the possession of Conval-Care, Inc. It is their intention to go to your clients place of business on Tuesday, October 22, 1991 and obtain these copies. I have attached a list of those records which are of interest. Please advise the undersigned if this date is inconvenient. Respondent's Exhibit No. 3. Some, but not all, of the listed records concerned patients for whom reimbursement between December of 1989 and November of 1990 was at issue in Case No. 91-4020. On October 21, 1991, in response to Mr. Scott's letter dated four days earlier, Respondent's Exhibit No. 3, Julie Gallagher wrote, on behalf of CCI: Section 400.487, F.S., grants HRS the authority to make "such inspections and investigations as are necessary in order to determine the state of compliance with the provisions of this act and of rules or standards in force pursuant thereto." It is our position that HRS has already made such "inspections and investigations" and has determined that Conval-Care, Inc. is not in compliance with various provisions of the statute and rules and, hence, HRS has initiated termination proceedings to exclude Conval-Care, Inc. from the Medicaid Program. Further "inspections and investigations" are not necessary as required by the statute and will, therefore, not be permitted. The other statute you cited, Section 409.903 [sic], F.S., has nothing to do with the inspection of documents. Should you desire documents from Conval-Care, Inc., which are pertinent to the issue in the pending litigation, please submit a discovery request and we will respond appropriately. Respondent's Exhibit No. 4. Insisting it had the right to inspect the records in question, HRS sent Ms. Williams to Palatka where, as CCI's counsel had forewarned, nobody from CCI was on hand to receive her. Main Case Abandoned "In the month or so preceding" (T.52) September 23, 1991, Ms. Williams came to believe "that what MFCU referred to . . . as their sample was not in fact a [random] sample . . . [and] did not encompass the entire billing period." Id. At hearing, she testified that she wanted "to determine an overpayment amount, irrespective of the termination proceeding." T.60. But at the time this desire arose HRS was seeking to recover the "overpayment amount" in Case No. 91-4020, the recoupment and termination proceeding in which final hearing was then set for October 14, 1991. HRS' counsel in the recoupment and termination proceeding relied on the attempt to obtain records Ms. Williams initiated on September 23, 1991, as his sole means of securing records that HRS listed as exhibits it intended to offer in the recoupment and termination proceeding, Case No. 91-4020. Petitioner's Exhibit No. 7.; T. 134-5. After the attempt to gather evidence in this fashion proved unavailing, and after several continuances, HRS dropped the recoupment and termination proceeding it had initiated against CCI.
Recommendation It is, accordingly, RECOMMENDED: That HRS dismiss the sanctions letter which initiated these proceedings. DONE AND ENTERED this 30th day of June, 1993, in Tallahassee, Florida. ROBERT T. BENTON, II Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 30th day of June, 1993.
Findings Of Fact Petitioner is an existing Medicaid provider. Specifically, Petitioner provides support coordination services to the developmentally disabled under the Development Services/Home and Community Based Services waiver support coordination program (Program). Petitioner has been a Program provider since 1993. The purpose of the Program is to prevent the institutionalization of developmentally disabled persons through the development of community supports and services. Florida and the federal government fund the Program, in accordance with the provisions of Title 42, Code of Federal Regulations, Sections 440.180 and 441. Traditionally, Respondent has been the primary agency in Florida responsible for discharging Florida's responsibilities under the Program. Chapters 96-387 and 95-393, Laws of Florida, transferred certain responsibilities under Medicaid from Respondent to the Agency for Health Care Administration. However, the Division of Developmental Services (Division), which is part of Respondent, continues to develop substantive policy under the Program. Under Section 393.001(9), Florida Statutes (1995), Respondent, primarily through the Division, receives and administers federal and state funds for the developmental disabilities program established under state and federal law. As a Program provider, Petitioner received a memorandum dated May 5, 1995, requiring that Petitioner execute a revised Medicaid provider agreement and waiver support assurances to continue to participate in the Medicaid program after July 1, 1996, as a provider of services in the Program. The memorandum warns that it serves as the required 30-day notice of termination of the existing agreement if Petitioner fails to sign and return the revised documents by the deadline. Petitioner signed and returned the revised documents by the deadline to continue to participate under the Program. The documents are a Medicaid support agreement, waiver support assurances, and an "HRS Developmental Services Process Monitoring Instrument Waiver Support Coordination May 10, 1996 Version" (Monitoring Instrument), of which the waiver support assurances are a part. This order refers to all of the revised documents collectively as the Revised Documents. Respondent has required all persons seeking to provide services under the Program to sign and deliver the Revised Documents. The Revised Documents contain different provisions from their predecessors in effect prior to July 1, 1996. The Medicaid provider agreement sets forth the general provisions governing Respondent and each provider under the Medicaid program. Many, though not all of these provisions, are the same as provisions of Section 409.907, Florida Statutes. The record does not demonstrate to what extent the contract provisions not found within Section 409.907 are the same as provisions of other state or federal statutes, rules and regulations, or case law. The record also does not demonstrate if variations between contract provisions and provisions of Section 409.907 are substantial. The revisions to the waiver support assurances, to which Petitioner objects, pertain to quality assurance. The monitoring instrument states, at page 3: Rather than continuing past policies of focusing state quality assurance efforts solely on traditional monitoring activities, [D]evelopmental [S]ervices is seeking to transform its current quality assurance system to one which elicits valued outcomes for the individuals served in conjunction with the overall service delivery system processes contributing to the achievement of these individualized outcomes. This process will lead to an enhanced system of quality assurance known as quality improvement. Toward this end, the monitoring instrument explains, at page 4: Around December 1993, a task force of providers, central office staff, program administrators and direct services staff was convened for the purpose of revisioning [sic] the traditional [D]evelopmental [S]ervices quality assurance system. . . . We believe the quality enhanced monitoring system described in this work book is the first step in moving development services toward a revisioned [sic] system of measuring quality. The Monitoring Instrument states the nature of the monitoring process, the requirements of self-assessment and recertification, the protocol for onsite monitoring by the Division, and the conditions for termination of a provider's services.
The Issue May the Department of Children and Family Services properly terminate Respondent as a Medicaid provider pursuant to its letters of March 6, 1996, and the same letter bearing the date, April 12, 1996? If the Department's termination was unlawful, may Respondent be awarded reinstatement and back "wages?" If the Department's termination was unlawful, may Respondent be awarded attorney's fees?
Findings Of Fact The Motion to Dismiss On March 6, 1996, the Agency served a termination letter upon Respondent Charest. Because that letter was not sent certified mail, the same letter was re-dated April 12, 1996, and served by certified mail. Respondent Charest timely requested formal hearing, pursuant to Chapter 120, Florida Statutes, but there was no request that a formal hearing be conducted within 90 days pursuant to Section 409.335, Florida Statutes. The Preliminary Statement, above, sets out the procedural history of this case before the Division of Administrative Hearings and is incorporated here by reference. The 1996 termination letter(s) provided, in pertinent part, as follows: This letter is to notify you of your termination as a Medicaid provider for a term of three (3) years. This termination also applies to your company, Family Choice Support Services. Since you were suspended effective May 1, 1995, the suspension of three years will run from that date, making you eligible to reapply for certification as of May 1, 1998. This termination is pursuant to §409.913(9)(b), Florida Statutes. Termination is authorized by the fact that you have violated the provisions of §409.13(8) by: Failing to provide Medicaid-related records on a timely basis as required under §409.913(8)(g). Failing to abide by the requirements of state law as required by §409.913(8)(h), in that you violated §409.919(2)(e) by offering Jackie Fagan compensation in return for referring clients to you. Also by submitting false or misleading information in connection with your application to qualify as a support coordinator eligible for Medicaid reimbursement in violation of §409.919(2)(g). Submitting applications and requests for reimbursement containing materially false or incorrect information in violation of §409.913(8)(j) and (k). (emphasis supplied) Paragraph 3 of the termination letters, alleging that Respondent had submitted requests for reimbursement containing materially false or incorrect information in violation of Section 409.913(8)(j) and (k), was orally dismissed by the Agency at the commencement of formal hearing. Respondent Charest previously had requested formal hearing in DOAH Case No. 95-3469. Charges in that case arose from April 24, 1995, and May 23, 1995, suspension letters similar to the March 6, 1996, and April 12, 1996, termination letters in the instant case. At the commencement of that formal hearing, Mr. Charest had moved to dismiss DOAH Case No. 95-3469 because the administrative complaint (the 1995 suspension letters) were based on an unadopted Agency rule. The DOAH Hearing Officer entered a December 15, 1995, Recommended Order which recommended that the Agency grant the Motion to Dismiss. The August 7, 1996, Agency Final Order read, in pertinent part, The department's certification termination letter cites only violation of certain unadopted rules. No other authority . . . is provided . . . . I must, therefore, concur . . . that the termination letter is facially deficient. Accordingly, it is ORDERED that the administrative action against petitioner's provider certification is dismissed. (emphasis supplied) At formal hearing in the instant case, Respondent moved to dismiss the 1996 termination letters. In part, he asserted that the formal hearing of June 11, 1997, was not timely, pursuant to Section 409.335, Florida Statutes.4 Respondent further asserted that the 1996 termination letters were vague because, pursuant to Section 409.913(9)(a), a suspension cannot be for more than one year, and the current charging documents were insufficient to advise him if he were subject to suspension or termination.5 The remaining thrust of Respondent's oral Motion to Dismiss was that due process had not been afforded to him because he had been given inadequate notice of the charges in the March 6, 1996, and April 12, 1996, termination letters because Sections 409.13(8), 409.919(2)(e), and 409.919(2)(g) do not exist. The Agency conceded that its citation to Section 409.13(8) in the second sentence of the 1996 termination letters was in error because the correct citation should have been to Section 409.913(8) Florida Statutes. The Agency also conceded that the termination letters' citation to Section 409.919(2)(e) and 409.919(2)(g) also should have been to 409.920(2)(e) and 409.920(2)(g), respectively. The undersigned orally denied Respondent's motion to dismiss and specifically found that there was clear and adequate pleading within the 1996 termination letters at least as to the statutory citations within numbered paragraphs 1 (Section 409.913(8)(g), Florida Statutes) and numbered paragraph 2 (Section 409.913(8)(h), Florida Statutes), and that under the circumstances of this case, the letter as a whole otherwise gave adequate notice of the charges Respondent would be called upon to defend against. However, the parties were also instructed that the issue of the statutory discrepancy in the 1996 termination letters could be re-visited in the parties' post-hearing proposals. The Merits Respondent began working as a Medicaid provider and support coordinator during February 1993. On June 20, 1993, Respondent signed a Florida Medicaid Provider Enrollment Application for certification as a Medicaid provider and was certified. On this application, Respondent answered "yes" to the question, "Have you or any principal owner in your business ever been convicted of a crime, plead nolo contendere to a crime or entered into a pretrial intervention program?" Respondent was certified, despite his affirmative answer, which related to a pre-1993 assault charge based on a dispute with a neighbor. No further Agency action ensued. Annual re-applications and re-certifications of provider status were anticipated, but due to creation of the Agency's new Geographic Service District 13, in order to comply with increased screening by the abuse-prevention registry, and because of missing paperwork for 1994, the Agency asked Respondent to apply for re-certification in December 1994. On December 13, 1994, Respondent signed a new Florida Medicaid Provider Enrollment Application for recertification. At that time, he answered "No," to the question, "Have you or any principal owner in your business ever been convicted of a crime, plead nolo contendere to a crime or entered into a pre-trial intervention program?" The Agency did not pursue the discrepancy between Respondent's June 20, 1993, and December 13, 1994, applications. However, a 1995 "screening," pursuant to Chapter 415, Florida Statutes, alerted Agency Medicaid personnel to the problem. When requested, Respondent provided the Agency with a 1993 "Disposition of Charges" on a domestic violence charge against him. That document is not in evidence, but apparently, it did not show that any pre-trial intervention had taken place and suggested that the case was dismissed. The Agency did not pursue the matter. At formal hearing, official recognition was taken of an "Announcement Of No Information" entered December 8, 1993, in State of Florida v. Charest, Marion County Court Case No. 93- 9765MM. Therein, the State Attorney in and for Marion County announced that the case would not be prosecuted on the basis that the defendant, (the Respondent herein) participated in, and successfully completed the Salvation Army Probation Pre-Trial Intervention Deferred Prosecution Domestic Violence Program. Respondent maintained that he had never received a copy of the Announcement of No Information and that no one had adequately informed him that the December 1993 domestic violence charges against him were not simply dismissed. However, he also admitted that he had been required to go to at least one session of counseling as a result of a 1993 domestic violence case and that this had occurred since he had filled out his original June 20, 1993, application. Considering Respondent's testimony concerning his work experience with the Department of Corrections and his 20 years as a mental health counselor, the undersigned does not find credible Respondent's protestations that he did not know that he had been involved in December 1993 in a pre-trial intervention program for domestic violence. Therefore, it is found that Respondent knowingly submitted false or misleading information on an application to the Medicaid Program for the purpose of being accepted as a Medicaid provider. Due to the vulnerability of the mentally challenged clients served by support coordinators, a charge of domestic violence and entry into a pre-trial intervention program are material to Respondent's fitness as a provider of services for the Agency's clients and should have been disclosed. Support plans are necessary to determine what services are appropriately reimbursable by Medicaid. The Agency experienced an ongoing problem in that most of its providers filed their "support plans" late, pursuant to Section 409.313(8)(g), Florida Statutes. Respondent's company submitted untimely reports in a greater degree than any other similar provider. Respondent was only one of two principals in his company. The Agency requested a Corrective Action Plan from Respondent, due April 1, 1994. Respondent's company continued to have chronically late plans after April 1, 1994. Respondent was cautioned on several occasions about the importance of timely submission of support plans, more particularly in a January 31, 1995, letter. Despite Respondent's hiring someone to assist him, five of eight reports attributable to him were still late just prior to his termination. Jackie Fagan is a staff member of the Key Learning Center operated by the Citrus County Association for Retarded Citizens. She was employed in that capacity in 1994 and 1995. Over several months in the latter part of 1994, Respondent negotiated with Ms. Fagan, trying to hire her for his company as a support coordinator. Ultimately, Respondent's increased salary offers did not entice Ms. Fagan to leave her 20- year employment with Key Learning Center. Part of the negotiations seem to have included Respondent's offer of a "bounty" to Ms. Fagan for each client who transferred to Respondent's company, when and if Ms. Fagan changed employments. There is no concensus on whether this would have been ethical. Even after she finally turned down Respondent, Ms. Fagan also understood Respondent to be offering her a bounty for any client she was able to sway to change to his company. Ms. Fagan clearly remembered that Respondent told her he would have to pay her off the premises of Key Training Center for this type of service. Susan Jaynes, who was Ms. Fagan's secretary, overheard Respondent say that if Ms. Fagan recommended clients to him, he "would make it worth her while." Originally, the Agency had required Respondent to bill Medicaid in quarter-hour increments, but at the time of Respondent's "bounty" conversations with Ms. Fagan after she had turned down his offer of employment, Medicaid paid support coordinators $147.00 per month for each client signed up with the support coordinator. Each support coordinator would have 30 to 35 clients at any one time. There was not a complete overlap of services between the type of services provided by Key Learning Center and Family Choice Support Services. However, where there was an overlap, the effect of Ms. Fagan proselytizing for Respondent would have been to persuade vulnerable mentally challenged clients and/or their supportive family members to change support coordinators for purely economic gain to Ms. Fagan and Respondent. It was contrary to Key Learning Center's ethical policy. Ms. Fagan also considered this type of persuasion ethically wrong. She reported it. Respondent established that if Key Learning Center employees simply handed out his advertising flyers, there would be no legal or ethical offense, although it was also shown that it was more common for him to mail his flyers directly to potential clients living in family homes. Respondent testified, without refutation or corroboration, that upon learning of his attempts to hire Ms. Fagan, the director of Key Learning Center had not permitted him to come on its premises to pick up and deliver mutual clients and had threatened Respondent that if he hired Ms. Fagan away, the director would see that Respondent lost all his own clients. Assuming, but not finding, that such a threat was actually made, it was never demonstrated that the director of Key Learning Center could carry out this alleged threat or that he ever approached or influenced the Agency to file charges against Respondent. The Agency suspended Respondent's certification on May 1, 1995, and the prosecution of DOAH Case No. 95-3469 then took the route described above in Finding of Fact 6. The Agency never restored Respondent's certification pending resolution of Respondent's first request for formal hearing in DOAH Case No. 95-3469. Respondent has been effectively decertified since May 1, 1995. He has been unable to draw on Medicaid funds pursuant to his certification since May 1, 1995. The 1996 termination letters in the instant case preceded exhaustion of any one year suspension under the 1995 suspension letters and also preceded the August 7, 1996, Final Order in the prior case. Even if de-certification had been frozen pending Section 120.57(1) proceedings, any certification existing on May 1, 1995, would have expired at the latest one year from its grant, pursuant to Respondent's December 13, 1994 application.
Recommendation Upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Department of Children and Family Services enter a Final Order ratifying its termination of Respondent's certification as a Medicaid individual support coordinator provider, retroactive to May 1, 1995. DONE AND ENTERED this 30th day of September, 1997, in Tallahassee, Leon County, Florida. ELLA JANE P. DAVIS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (904) 488-9675 SUNCOM 278-9675 Fax Filing (904) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 30th day of September, 1997.
